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S: Subjective
Chief complaint: "My sinuses have been blocked for almost two weeks."
History of present illness: A 34-year-old woman reports nasal congestion and thick yellow-green nasal discharge for 12 days, which started with a sore throat and runny nose. She has had pressure over both cheeks, worse when bending forward, and a reduced sense of smell. She felt slightly better around day 5 but has not improved since. Highest temperature 37.9 °C. No vision changes, eye swelling, severe headache or neck stiffness. Over-the-counter decongestants helped briefly.
Past medical history: Seasonal allergic rhinitis. No asthma. No sinus surgery. Medications: Cetirizine 10 mg daily in spring. Allergies: No known drug allergies. Social history: Nonsmoker; works as a teacher.
O: Objective
- Vital signs: temperature 37.6 °C, heart rate 82, respiratory rate 16, blood pressure 118/74, SpO₂ 99%.
- HEENT: nasal mucosa red and swollen with purulent discharge on both sides; tenderness over both maxillary sinuses; tympanic membranes normal; mild throat redness without exudate; no swelling around the eyes; extraocular movements full.
- Neck: supple; small, mobile, nontender anterior cervical nodes.
- Lungs: clear.
A: Assessment
Acute bacterial rhinosinusitis. The Infectious Diseases Society of America (IDSA) guideline identifies bacterial infection by one of three clinical patterns: persistent symptoms lasting 10 days or more without improvement; severe onset, with a fever of 39 °C or higher and purulent discharge or facial pain for 3 to 4 consecutive days at the start; or worsening symptoms after initial improvement, the "double sickening" pattern (Chow et al., 2012). She meets the first criterion, with 12 days of symptoms and no improvement since day 5.
Differential diagnoses:
- Viral rhinosinusitis: less likely, because most viral illnesses improve within 10 days.
- Allergic rhinitis flare: possible contributor, given her history, but purulent discharge and facial pain point to infection.
- Dental infection: no tooth pain or dental tenderness.
- Complicated sinusitis (orbital or intracranial spread): no warning signs present.
P: Plan
- Antibiotic: amoxicillin-clavulanate, the guideline's recommended first-line choice over amoxicillin alone, 875 mg/125 mg twice daily for 5 to 7 days, the duration it recommends for adults without risk factors for resistance (Chow et al., 2012). For a penicillin allergy, doxycycline would be an alternative.
- Adjunctive care: saline nasal irrigation; an intranasal corticosteroid, which the guideline suggests particularly for patients with a history of allergic rhinitis; acetaminophen or ibuprofen for pain.
- Not recommended: routine imaging, and antihistamines or decongestants as treatment for the infection.
- Teaching: finish the full course; expect improvement within 3 to 5 days.
- Return precautions: seek care right away for swelling or redness around the eyes, double vision or vision changes, severe headache, stiff neck, confusion or a high fever.
- Follow-up: if no improvement within 3 to 5 days or symptoms worsen, return for reassessment and a change of antibiotic.
Reference
Chow, A. W., Benninger, M. S., Brook, I., Brozek, J. L., Goldstein, E. J. C., Hicks, L. A., Pankey, G. A., Seleznick, M., Volturo, G., Wald, E. R., & File, T. M., Jr. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases, 54(8), e72–e112. https://doi.org/10.1093/cid/cis370
